Provider Demographics
NPI:1598784027
Name:SERINO, ROBERT MICHAEL (PH D)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:MICHAEL
Last Name:SERINO
Suffix:
Gender:M
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4900 FAIRFIELD CIR
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38117-4210
Mailing Address - Country:US
Mailing Address - Phone:901-761-0452
Mailing Address - Fax:800-572-6370
Practice Address - Street 1:5170 SANDERLIN AVE
Practice Address - Street 2:SUITE 204
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38117-4360
Practice Address - Country:US
Practice Address - Phone:901-761-2622
Practice Address - Fax:901-761-2355
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2011-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR78-24P103T00000X
TNP551103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN104142OtherVALUE OPTIONS
TN0013747OtherBLUE CROSS/BLUE SHIELD
TN0013747OtherBLUE CROSS/BLUE SHIELD
TN3680253Medicare ID - Type Unspecified